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Diagnosis: Turf War

In Texas, nurse practitioners’ livelihoods are tied to physicians: By law, they can’t treat patients without a doctor’s permission. That means if they want to open their own practice, they must petition, and pay, a doctor to grant them “prescriptive authority” — to essentially keep an eye on their work and, in some cases, to be held liable for it. Doctors say this is as it should be. Nurse practitioners and their allies say doctors don't want the competition and charge them enough to run them out of business. “It borders on an immoral situation,” says state Rep. Wayne Christian, R-Center.

Family nurse practitioner Jean Gisler at her office in Victoria, Texas.

Prudie Orr is a licensed psychiatric nurse practitioner, but these days she feels more like an aspiring indentured servant. Since moving to the Central Texas town of Georgetown in December, she’s been unable to open a practice and see patients — because she can’t find a doctor who will allow it. “I’ve gone up and down the telephone book, calling every psychiatrist in town,” she says. “I have to go hat in hand to these folks to see if they will grant me the privilege of making a living.”  

In Texas, nurse practitioners’ livelihoods are tied to physicians; by law, they can’t treat patients or prescribe medicine without having a doctor’s permission. That means that if they want to open their own practice, they must petition, and pay, a local physician to grant them “prescriptive authority,” essentially keeping an eye on the nurse practitioner’s work — and in some cases, being held liable for it.  

Doctors say this is as it should be. They say that even the most skilled advanced practice nurses receive just a fraction of the medical training family practice doctors get — a maximum of 5,300 hours, compared to doctors’ 20,000 hours, according to an analysis by the American Academy of Family Physicians. And they don’t go through grueling residency programs like doctors do, the physicians say, leaving them less prepared to handle emergencies or unusual conditions.  

“The focus of nursing school is different than the focus of medical school. If you want to practice medicine, you have to go to medical school,” says Dr. Gary Floyd, a Fort Worth physician who serves on the Texas Medical Association’s Council on Legislation. “The midlevel practitioners are incredibly important to our health care team. But it has to be a team. And the physicians are better-equipped to lead that team because of their educational base.”

Nurse practitioners say the relationship is an antiquated encumbrance — and instigates a nasty turf battle. Often, doctors won’t grant them “prescriptive authority” because they don’t want the competition, these nurse practitioners say. In other cases, they say the doctors charge them exorbitant fees to oversee them, costs that run them out of business. Some doctors simply don’t want the responsibility, or the paperwork and monitoring that comes with being a “delegating physician.”

“It borders on an immoral situation,” says state Rep. Wayne Christian, R-Center, who has filed legislation to free nurse practitioners from the so-called “prescriptive authority” rules. “We have prevented citizens of this state from receiving quality medical care because legislators have listened to the bias of certain organizations.”

Advanced practice nurses first got the right to prescribe in Texas in 1989 — but only with a doctor’s permission, only with very limited drugs and only in rural and medically underserved areas. Over the next 15 years, these nurse practitioners battled for and won the right to practice in many other health care settings, in a variety of communities, and even to prescribe some controlled substances, but have remained beholden to doctors for this authority.

Now, after a seven-year ceasefire, the advanced practice nurses are fighting to sever the doctor relationship all together, and they’re doing it with health care reform as their platform. With up to 6 million more Texans soon to be insured, and an already dire shortage of primary care physicians, particularly in rural Texas, nurse practitioners say Texas must do what more than a dozen other states have already done: remove the barriers that keep advanced practice nurses out of independent practice. “When you see the shortage of primary care in Texas, it’s staggering,” says Lynda Woolbert, executive director of the Coalition for Nurses in Advanced Practice. “Patients need help managing chronic illnesses; they need well-child exams — all things that aren’t physicians’ strongest suits.”  

Physician groups say the argument that nurse practitioners would fill the primary care physician gap is preposterous, because there simply aren’t enough of them to make a dent. In fact, they say, if nurse practitioners are given greater authority to act independently, fewer doctors will go into family practice. “If I’m a student looking at the time and cost it’s going to take me to go out and get an M.D., and I look at someone with much less training and clinical experience being given the ability to do the same thing, that’s going to be a huge disincentive for me to go into primary care,” says Tom Banning, CEO of the Texas Academy of Family Physicians.

Floyd says current workforce problems could be curbed by helping more physician assistants and nurse practitioners get the additional education they need to become doctors — not by giving them more responsibility without more training. He said he works closely with nurse practitioners, and when he asks them if they want to operate independently without doctors, “they look at me like I grew four horns.”

“Our guys don’t even want to be left alone because of what might walk in,” Floyd says. “It’s no fun being in a situation when you don’t know what to do and you don’t know who you can call.”

Advanced practice nurses say the argument that they’re not qualified to care for patients without a doctor’s oversight is flat-out false. They point to a 2000 study published in the Journal of the American Medical Association that found patients treated by fully authorized nurse practitioners fared just as well as patients treated by physicians. Physicians say this study is hardly the last word on the debate. An article published in the American Medical Association Journal of Ethics early this year said the jury is still out on whether nurse practitioners are as effective as doctors — and that previous studies on the topic, including the 2000 JAMA study, were lacking or incomplete. 

Today, state rules limit the number of nurse practitioners a single doctor can oversee, and cap how far a nurse practitioner can work from a supervising doctor — all points of frustration for nurses trying to practice in remote or underserved communities. Physicians can seek waivers to these rules, but the nurse practitioner has to convince them to do it. The bottom line, advanced practice nurses say, is that nurse practitioners’ hands are tied if they don’t have a primary care doctor close at hand, or the connections to get a doctor to go to bat for them.

When Victoria nurse practitioner Jean Gisler decided to go out on her own with more than 30 years of nursing experience, she never dreamed she’d have trouble opening a practice. She had known the community’s family practice doctors and worked closely with them for years. But once she looked like a potential competitor, she says, none of these doctors would grant her prescriptive authority. One said it would take too much time and energy. Another said he didn’t want the responsibility or liability. The doctor she finally convinced — after nine months of begging — charged her $2,000 a month to collaborate, plus rent to practice in an office connected to his.

Gisler has partnered with this doctor for six years, she says, bringing him business and hospital referrals with very little effort on his part. But if something happened to him, or to their relationship, she says, she’d have no fallback plan — and her patients would go without care. “If he died tonight, tomorrow I could not take care of the 5,000 patients I manage,” Gisler says. “I couldn’t write a prescription. I couldn’t diagnose them. I couldn’t treat them at all.”

The situation is even more difficult for nurse practitioners who are new to Texas, or don’t have ties to the local medical community. Orr, who left a thriving practice in Tennessee to be closer to her grandchildren in Texas, is so frustrated trying to find a psychiatrist to partner with in Williamson County that she’s getting licensed in Arizona to treat patients there via telemedicine. “I live in a medically underserved area and would be love to be treating patients here,” she says. “Instead, I’m going to sit at my house and treat people in Arizona by web cam.”

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